Rowley Cottingham wrote:-
>Thiopentone is no longer a good choice, and propofol
is much better. I don't understand Adrian Fogerty's
concerns about oxygenation
>in GA; with RSI paralysis it is the optimum method for
gaining control of the airway. There is a case for simply
giving suxamethonium as
>the patient is unconscious from the fit and also from
the benzodiazepine already given.

hmmm, an argument maybe but not what I would do. 0

There does seem to be some benefit to Propofol in
these situations, though whether it is better than
thiopentone is unproven (see abstracts below)

Simon


Citation 1
Unique Identifier
20468096
Authors
Starreveld E. Starreveld AA.
Institution
Adult Convulsive Disorder Clinic, Glenrose Rehabilitation
Hospital.
[log in to unmask]
Title
Status epilepticus. Current concepts and management.
[Review] [35 refs]
Source
Canadian Family Physician. 46:1817-23, 2000 Sep.
Abstract
OBJECTIVE: To inform primary care physicians about
current issues around generalized convulsive status
epilepticus (GCSE) emphasizing definition,
pathophysiology, treatment, and prognosis. QUALITY
OF EVIDENCE: MEDLINE (1994 to 1999) provided 479
references using the MeSH terms "status epilepticus"
and "treatment." From these we selected 30 English-
language articles covering clinical aspects, treatment,
and animal research. Key source documents from
previous years and information from modern textbooks
and recent symposia were also included. MAIN
MESSAGE: Generalized convulsive status epilepticus
continues to be a medical emergency with high
morbidity and mortality. It must be managed promptly
and effectively. The operational definition of GCSE is a
seizure that lasts longer than 5 minutes or two or more
seizures between which patients do not recover. Main
differential diagnosis is nonepileptic status. Intravenous
therapy with combined lorazepam and phenytoin is the
initial treatment of choice. Other preferred medications
are diazepam, midazolam, and propofol. Some of these
medications should be considered before arrival at
hospital. Prognosis of GCSE is determined by underlying
cause, delay in adequate treatment, and comorbidity.
Patients with GCSE lasting longer than 30 minutes
require intensive care and electroencephalogram
monitoring. CONCLUSION: Intravenous lorazepam and
phenytoin are currently the most effective drugs for
initial management of GCSE. Timely administration of
antiepileptic medication can prevent development of
GCSE in some patients with known epilepsy. Main
differential diagnosis is nonepileptic status.
[References: 35]

Go to ... Help | Logoff
Citation 2
Unique Identifier
99010013
Authors
Brown LA. Levin GM.
Institution
Department of Pharmacy Practice, Albany College of
Pharmacy, NY, USA.
Title
Role of propofol in refractory status epilepticus. [Review]
[33 refs]
Source
Annals of Pharmacotherapy. 32(10):1053-9, 1998 Oct.
Abstract
OBJECTIVE: To provide a review of the proposed
mechanism of action, clinical efficacy, adverse effects,
and therapeutic considerations associated with the use
of propofol in the management of patients with
refractory status epilepticus. DATA SOURCES: A MEDLINE
database (January 1966-April 1998) was searched for
literature pertaining to status epilepticus and propofol.
Additional literature was obtained from the references of
selected articles identified in the search. Information
from all articles published in English was considered for
inclusion in the article. DATA SYNTHESIS: Propofol is a
unique, nonbarbiturate, anesthetic agent possessing
anticonvulsant properties, although the exact
anticonvulsant mechanism is unknown. Several case
reports and two small, open, uncontrolled studies have
described the efficacy of propofol in refractory status
epilepticus. Most of these clinical reports discuss the
utility of propofol after traditional treatment regimens
have failed or are not tolerated. Initiation of propofol
usually resulted in termination of seizure activity and/or
electroencephalographic burst suppression within
seconds that was sustained during the drug's use.
Additionally, propofol was well tolerated. Advantages of
propofol compared with traditional barbiturate anesthetic
agents include better cardiovascular tolerability and a
more favorable pharmacokinetic profile, allowing for
rapid assessment of efficacy and neurologic assessment
upon drug withdrawal. Propofol has been associated with
a variety of neuroexcitatory adverse events such as
opisthotonos, muscle rigidity, and choreoathetoid
movements. Additionally, although the data are
inconclusive, propofol has also been reported to cause
seizures. CONCLUSIONS: Propofol has shown promising
results in the management of refractory status
epilepticus when traditional therapies have failed or
were not tolerated; however, controlled clinical trials are
needed to better assess the comparative efficacy,
neurologic adverse effects, and clinical outcome to
better define its role in refractory status epilepticus.
[References: 33]

Go to ... Help | Logoff
Citation 3
Unique Identifier
98096677
Authors
Harrison AM. Lugo RA. Schunk JE.
Institution
Department of Pediatrics, University of Utah School of
Medicine, Salt Lake
City, USA.
Title
Treatment of convulsive status epilepticus with propofol:
case report [see comments].
Comments
Comment in: Pediatr Emerg Care 1998 Jun;14(3):248-9
Source
Pediatric Emergency Care. 13(6):420-2, 1997 Dec.
Abstract
INTRODUCTION: Convulsive status epilepticus (CSE)
refractory to treatment with benzodiazepines,
phenobarbital, and phenytoin presents a challenge to
pediatric emergency and critical care specialists. Prompt
seizure control may prevent mortality and morbidity.
CASE: A nine-month-old girl with hereditary fructose
intolerance had prolonged, refractory CSE. Her seizures
promptly stopped after administration of propofol (3
mg/kg bolus followed by infusion of 100
micrograms/kg/min). This dose resulted in
electroencephalographic burst suppression. She required
endotracheal intubation, invasive hemodynamic
monitoring, and pressor support. DISCUSSION: This is
the first pediatric case of prolonged, refractory CSE
treated with propofol. The adult experience is reviewed.
Propofol should be used only in a setting where
definitive airway control and hemodynamic support is
possible.

Go to ... Help | Logoff
Citation 4
Unique Identifier
97346516
Authors
Borgeat A.
Institution
Department of Orthopaedics, Klinik Balgrist, University
of Zurich,
Switzerland.
Title
Propofol: pro- or anticonvulsant?. [Review] [32 refs]
Source
European Journal of Anaesthesiology - Supplement.
15:17-20, 1997 May.
Abstract
The pro- or anticonvulsant properties of propofol remain
a matter of controversy. Although numerous case
reports describe the appearance of abnormal
movements, posturing and seizure-like activity related
to the use of propofol, systematic studies in both
humans and animals strongly suggest that it possesses
antiepileptic properties. Propofol consistently reduces
the seizure duration during electroconvulsive therapy, its
use has been successful in controlling refractory status
epilepticus and in animals it offers a strong protection
against lignocaine- or pentylene-tetrazol-induced
epilepsy. The beneficial effects of propofol may be
related to its uniform depressant action on the central
nervous system, to a potentialization of GABA-mediated
pre- and postsynaptic inhibition, and by decreasing the
release of excitatory transmitters, glutamate and
aspartate. [References: 32]

Go to ... Full Text | Help | Logoff
Citation 5
Unique Identifier
96310704
Authors
Cascino GD.
Institution
Department of Neurology, Mayo Clinic Rochester,
Minnesota, USA.
Title
Generalized convulsive status epilepticus.
Source
Mayo Clinic Proceedings. 71(8):787-92, 1996 Aug.
Abstract
Generalized convulsive status epilepticus (GCSE) is a
medical emergency that may be associated with severe
neuronal injury. The mortality attributable to GCSE
ranges from 3 to 35%. The disorder occurs most
frequently in the young and the old extremes of the
population. GCSE commonly occurs in patients with no
history of seizures or epilepsy. The morbidity associated
with status epilepticus is related to the underlying
precipitating factors, age of the patient, and duration of
seizure activity. Morbidity and mortality are highest in
elderly patients and those with acute symptomatic
seizures--for example, GCSE related to anoxia or
cerebral infarction. Mortality is lowest among pediatric
patients and patients with unprovoked seizures or GCSE
related to low antiepileptic drug levels. Intravenously
administered diazepam or lorazepam and phenytoin
remain the first-line therapy for GCSE. More than half
the patients will respond to initial treatment. Patients
with refractory status epilepticus require a physician with
expertise in epilepsy. Treatment options include
pentobarbital, high-dose phenobarbital, or inhalation
anesthetic agents.

Go to ... Help | Logoff
Citation 6
Unique Identifier
92229276
Authors
Campostrini R. Bati MB. Giorgi C. Palumbo P. Serra P.
Vinattieri A. Cantini A. Martini E.
Institution
U.O. Neurologia, USL 9, Prato.
Title
Propofol in the treatment of convulsive status
epilepticus:
a report of four cases.
Source
Rivista di Neurologia. 61(5):176-9, 1991 Sep-Oct.
Abstract
Propofol is a new anaesthetic agent commonly used
because of its rapid pharmacokinetic. Lately, anecdotal
reports suggest its utility in the treatment of convulsive
status epilepticus. We describe four cases of convulsive
status due to severe encephalopathy of various
etiology. They were resistant to diazepam and other
drugs and remitted only after treatment with propofol.
The infusion, even protracted to 8 days, did not cause
any toxic or proconvulsive side-effects. The very short
duration of its central depressant action permitted
monitoring of the underlying neurological status
whenever needed.

Go to ... Help | Logoff
Citation 7
Unique Identifier
91119105
Authors
Mackenzie SJ. Kapadia F. Grant IS.
Institution
Intensive Therapy Unit, Western General Hospital,
Edinburgh.
Title
Propofol infusion for control of status epilepticus.
Source
Anaesthesia. 45(12):1043-5, 1990 Dec.
Abstract
Two patients with status epilepticus who were resistant
to conventional treatment but responded to propofol
infusions are reported. An electroencephalogram
confirmed the seizures and their successful treatment.


>